Patients are prepared to attend to the memory and associations while their attention is also engaged by a bilateral physical stimulation eye movements, taps or tones. Each target is accessed individually according to procedures that bring together all the relevant cognitive, emotional and sensory aspects of the traumatic memory. Then, the patient is guided into a receptive state of awareness regarding aspects of the targeted event, and any concomitant memory associations. Desensitisation, de-arousal, insights and changes in belief are viewed as by-products of this direct processing, which is posited to move the targeted event from implicit memory to explicit memory, which no longer contains the disturbing affects, thoughts and sensations.
It is postulated, first, that what is useful is learned, stored with appropriate affects and is able to guide the person in the future, and second, that what is not useful the negative emotions, thoughts and sensations is progressively discarded as part of the transformation of the memory.
The EMDR procedures are also used to elicit and strengthen positive affects, cognitions and future behaviours. The eye movement element of EMDR has attracted the most attention; however, Shapiro has emphasised in her recent writing e. Shapiro, , that EMDR is a multiple-stage therapy that is meant to be integrated into a comprehensive plan for the treatment of trauma.
Many of the procedures used in EMDR overlap with those used in trauma-focused CBT ; for example, holding an image of the trauma in mind resembles imaginal exposure, although the exposure is much briefer and the patient does not verbalise the content of the image. Replacing negative cognitions associated with the trauma with positive cognitions overlaps with cognitive interventions.
The associative techniques resemble those used in psychodynamic approaches. This has led several recent reviews to conclude that the effectiveness of EMDR may be due to these common treatment components, rather than the eye movements e. However, the treatment originator and other authors maintain that rhythmic bilateral stimulation is an important therapeutic element e. Despite the similarity in many treatment procedures, EMDR was considered separately from CBT approaches for the purposes of the meta-analysis, as its originator considers it a distinct treatment Shapiro, , and specific training programmes are required.
A range of other psychological treatments are currently used in the NHS to treat trauma survivors. As the empirical evidence base for each of these treatments is sparse, they were combined for the purposes of the review. It is important to note, however, that the different treatments have different rationales and procedures. Supportive therapy builds on the concept of client-centred therapy by Rogers It is defined here as equivalent to non-directive counselling and as a way for the individual to explore how they relate and respond to another person.
In supportive therapy individuals are helped to focus on their thoughts, feelings and behaviour; reach clearer self-understanding; and to find and use their strengths so that they cope more effectively with their lives by making appropriate decisions, or by taking relevant action. Essentially, supportive therapy is a purposeful relationship in which one person helps another to help themselves. Supportive therapy is primarily non-directive and non-advisory, but recognises that some situations require positive guidance by means of information and advice Hoxter, , cited by Bond, One RCT also encouraged patients to explore coping strategies that they had used to cope with earlier life events Blanchard et al , b.
Several different forms of psychodynamic treatments for PTSD have been described see Garland, ; Kudler et al , , for an overview;. The emphasis in psychodynamic therapies lies on resolving the unconscious conflicts provoked by the stressful event.
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Treatment strategies include exploratory insight-oriented, supportive or directive activity. It may also include working with transference, but with the therapist using a less strict technique than that used in psychoanalysis.
Hypnotherapy involves giving the patient instructions e. The goal is to enhance control over trauma-related emotional distress and hyperarousal symptoms and to facilitate the recollection of details of the traumatic event. In summary, the systematic review classified the psychological treatment programmes as follows.
Two of the treatment categories — trauma-focused CBT and EMDR — focus on the memory for the traumatic event and its meaning; these are referred to as trauma-focused psychological treatments throughout this guideline.
The above four categories refer to treatments that are delivered on an individual basis; the final category was group cognitive—behavioural therapies. Several previous systematic reviews of psychological treatments have been conducted. The practice guidelines from the International Society for Traumatic Stress Studies Foa et al , came to similar conclusions. Several systematic reviews highlight the exposure to the memory of the traumatic event and reminders of the trauma as common elements of effective trauma treatments Paunovic, ; Rothbaum et al , Previous meta-analyses included both controlled and uncontrolled studies.
This review, in line with the procedure set out in Chapter 4 , only included RCTs. In addition to the generic inclusion criteria listed in Chapter 4 , further inclusion criteria were that the intervention did not occur less than 3 months after the trauma earlier interventions are considered in Chapter 7 , and that treatment entailed more than one intervention session. Therefore, the analysis of the continuous assessor-rated and self-reported symptom scores is a completer analysis.
This type of analysis may overestimate treatment effectiveness, as one may expect that people who withdraw from treatment may on average respond less well than those who complete the treatment. To compensate for this potential bias, the percentage of people who still met diagnostic criteria for PTSD at the end of treatment was calculated as an intent-to-treat analysis. This analysis made the conservative assumption that people who did not complete the treatment still met diagnostic criteria. When making recommendations, we considered completer analyses for self-reported and clinician-rated PTSD symptoms, and intent-to-treat analyses for the number of the people still suffering from PTSD, together to form an overall estimate of treatment effectiveness.
Three further types of treatment outcome were considered as additional criteria. First, in order to evaluate the acceptability of the treatments, the percentage of people who did not complete treatment or any comparable active intervention was recorded.
Second, we reviewed whether the treatment of PTSD also led to significant improvement in symptoms of depression and anxiety. However, in general, these measures focused on impairment in functioning rather than positive aspects of quality of life. The review team conducted a new systematic research for RCTs of each of the five therapy groupings outlined above trauma-focused CBT , EMDR , stress management, group CBT and other therapies that compared these treatments against waiting list or usual care or against another psychological treatment.
The following studies were identified by the Guideline Development Group as meeting the inclusion criteria. Full details of the search strategy for this and other reviews of the guideline are given in Appendix 6. Information about each study along with an assessment of methodological quality is given in Appendix 14 , which also contains a list of excluded studies with reasons for exclusions.
Two additional RCTs met inclusion criteria, but differed in mode of delivery and are discussed separately in section 5.
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The full list of evidence statements is given in Appendix The full range of outcome measures was not provided in the three studies of group CBT. Although many of the included studies compared active treatments against waiting list, there were fewer studies available for direct comparisons of each of the active treatments against one another. The comparisons are set out in the following order.
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Each treatment is considered in turn in the same order as in the preceding section trauma-focused CBT , EMDR , stress management and other therapies. So the first treatment considered in the review, trauma-focused CBT, is compared against each of the other classifications of treatments in turn except group CBT, for which no study provided a direct comparison.
Next, EMDR is compared against each of the remaining treatments for which a direct comparison has not already been provided therefore the comparison against trauma-focused CBT is not repeated.
Hence for stress management only one comparison is listed directly against other therapies , as all other comparisons have already been listed. Where available, three outcome measures are reported for each comparison in the following section: a self-report measure of the severity of PTSD symptoms or where this is not reported, the clinician-rated measure , likelihood of having a PTSD diagnosis, and leaving treatment early.
In addition, there was limited evidence that this therapy also has clinically important effects on depression and anxiety. Treatment duration ranged between 4 and 18 sessions, and the duration of sessions was between 50 min and min. The effectiveness of EMDR was also generally supported by the meta-analysis, but the evidence base was not as strong as that for trauma-focused CBT , both in terms of the number of RCTs available and the certainty with which clinical benefit was established.
In addition, there was evidence or limited evidence for clinically important effects on anxiety and depression. Treatment duration ranged between 2 and 12 sessions, and the duration of sessions was between 50 min and 97 min. Direct comparisons of these two approaches did not reveal any significant advantages for one over the other, with respect to either treatment outcome or the speed of therapeutic change Taylor et al , However, there were very few studies of the latter two approaches.
Thus the review did not find support for any clinically important benefits of these treatments, although this does not mean that these treatments were shown to be ineffective. For stress management and relaxation there was limited evidence for clinical effects on some measures when compared with waiting lists, but no consistent differences in effectiveness compared with other treatments. This may be due to the overlap of stress inoculation training with the cognitive components of trauma-focused CBT.
Psychological group treatments have rarely been investigated. However, a sub-analysis of participants who received an adequate amount of therapy showed some evidence that trauma-focused group CBT had advantages over non-trauma-focused group treatment. Considerable concern is often expressed about whether the results of clinical trials can generalise to routine clinical practice in the NHS.
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